What is the best management approach for an elderly patient with CKD (Chronic Kidney Disease), uncontrolled HTN (Hypertension), and recent Hyperkalemia, who is experiencing eyelid twitching and facial movement changes, and has previously been on felodipine and losartan (Angiotensin II Receptor Blocker (ARB)) which were discontinued due to hyperkalemia?

Management of Elderly Patient with CKD, Uncontrolled Hypertension, Recent Hyperkalemia, and Neurological Symptoms

Immediate Priority: Evaluate Eyelid Twitching and Facial Movement Changes

The eyelid twitching and facial movement changes require urgent evaluation for uremic complications, given the severely reduced eGFR of 14-16. These symptoms may represent uremic encephalopathy, electrolyte disturbances (hypocalcemia, hypomagnesemia), or other metabolic derangements requiring immediate assessment 1.

• Obtain comprehensive metabolic panel including calcium, magnesium, phosphate, and bicarbonate to rule out metabolic causes 1
• Consider neurology consultation if symptoms persist or worsen, as uremic toxins can cause movement disorders at eGFR <15 mL/min 1
• Assess for other uremic symptoms: confusion, asterixis, pruritus, nausea, or metallic taste 1

Hyperkalemia Management: Maintain RAAS Inhibition While Controlling Potassium

Do not permanently discontinue losartan despite the recent hyperkalemia—instead, use newer potassium binders to enable continuation of this life-saving medication. 2, 1

Current Status Assessment

• Potassium trending down from 6.2 to 5.7 mEq/L indicates improvement but remains above optimal range 1
• At eGFR 14-16, this patient is at extremely high risk for recurrent hyperkalemia 2, 3
• The combination of losartan and felodipine was appropriate therapy that should be resumed with potassium management 2

Specific Management Algorithm

Step 1: Initiate Potassium Binder Therapy

• Start sodium zirconium cyclosilicate (SZC/Lokelma) 10g three times daily for 48 hours, then 5-10g once daily for maintenance 1
• Alternative: Patiromer (Veltassa) 8.4g once daily, titrated up to 25.2g daily based on potassium levels 1
• SZC is preferred in this case due to rapid onset (~1 hour) and the need for quick control before restarting antihypertensives 1
• Avoid sodium polystyrene sulfonate (Kayexalate) due to risk of bowel necrosis, especially in elderly patients 1, 4

Step 2: Restart RAAS Inhibitor at Reduced Dose

• Once potassium <5.0 mEq/L, restart losartan at 25mg daily (half the previous dose) 2, 1, 4
• RAAS inhibitors slow CKD progression even at eGFR 14-16 and should be continued unless eGFR <15 with uremic symptoms 2
• Monitor potassium and creatinine within 3-7 days after restarting 2, 4

Step 3: Address Hypertension with Additional Agents

• Restart felodipine 5mg daily (or alternative long-acting dihydropyridine calcium channel blocker) once losartan is restarted 2, 5
• Target BP <130/80 mmHg in CKD patients, though <140/90 is acceptable in elderly patients to avoid hypotension 2, 5
• Consider adding low-dose loop diuretic (furosemide 20-40mg daily) to enhance potassium excretion and control volume 1, 5

Critical Monitoring Protocol

• Check potassium and renal function within 3 days after initiating potassium binder 1, 4
• Recheck at 7 days after restarting losartan 2, 4
• Continue weekly monitoring until potassium stable between 4.0-5.0 mEq/L 1, 4
• In advanced CKD (stage 4-5), acceptable range is 4.0-5.5 mEq/L due to compensatory mechanisms 1
• Monitor for hypokalemia with potassium binders, as overcorrection can be more dangerous than mild hyperkalemia 1, 4

Dietary and Medication Counseling

Implement moderate dietary potassium restriction (2000-3000mg/day) rather than severe restriction (<2000mg/day). 1

• Avoid high-potassium foods: bananas, oranges, tomatoes, potatoes, salt substitutes 1
• Stringent dietary restrictions may not be necessary with potassium binder therapy and can compromise nutritional status 1
• Eliminate NSAIDs entirely—they worsen renal function and dramatically increase hyperkalemia risk with losartan 6, 5
• Avoid potassium supplements and herbal supplements (alfalfa, dandelion, horsetail, nettle) 1

Addressing Uncontrolled Hypertension (BP 177/69)

The elevated systolic BP requires treatment, but the relatively low diastolic BP (69 mmHg) necessitates careful agent selection to avoid excessive diastolic hypotension. 5

Antihypertensive Strategy

• Restart losartan 25mg daily as first-line agent (provides both BP control and renoprotection) 2, 5
• Add felodipine 5mg daily (long-acting dihydropyridine CCB) as second-line agent 5
• If BP remains >140/90 after 2-4 weeks, consider adding chlorthalidone 12.5mg daily (thiazide-like diuretic effective even at eGFR 14-16) 5
• Avoid beta-blockers as they can worsen hyperkalemia and may not be first-line in this patient 1

BP Monitoring

• Obtain ambulatory BP monitoring (ABPM) or home BP monitoring to confirm office readings 2
• Target systolic BP 130-140 mmHg in elderly patients with CKD to balance cardiovascular protection against fall risk 2, 5
• Avoid aggressive BP lowering (SBP <120) in elderly patients due to increased risk of acute kidney injury and falls 2

Management of Advanced CKD (eGFR 14-16)

At eGFR 14-16, this patient is approaching the need for renal replacement therapy and requires nephrology co-management. 2, 4

Nephrology Referral and Planning

• Ensure active nephrology follow-up for dialysis planning and vascular access evaluation 2
• Discuss goals of care, including options for dialysis (hemodialysis vs. peritoneal dialysis) or conservative management 2
• Consider initiating SGLT2 inhibitor if not already on one, as they provide cardiovascular and renal benefits even at eGFR <20 2

Metabolic Complications of CKD

• Check intact PTH, vitamin D, calcium, and phosphate to assess for CKD-mineral bone disorder 2
• Assess for anemia (target hemoglobin 10-11.5 g/dL with ESA or iron supplementation) 2
• Evaluate metabolic acidosis (if bicarbonate <22 mEq/L, consider sodium bicarbonate supplementation) 1, 4

Common Pitfalls to Avoid

Never permanently discontinue RAAS inhibitors in CKD patients with proteinuria—this leads to worse cardiovascular and renal outcomes. 2, 1, 4

• Do not use dual RAAS blockade (ACEi + ARB, or either with direct renin inhibitor)—this markedly increases hyperkalemia risk without additional benefit 2, 6, 3
• Avoid combining losartan with potassium-sparing diuretics (spironolactone, amiloride, triamterene) at this eGFR without very close monitoring 1, 6, 7
• Do not use sodium bicarbonate for hyperkalemia unless metabolic acidosis is documented (pH <7.35, bicarbonate <22 mEq/L) 1, 4
• Never delay evaluation of new neurological symptoms in advanced CKD—they may indicate uremic encephalopathy requiring urgent dialysis 1
• Avoid volume depletion with diuretics, as this can precipitate acute-on-chronic kidney injury and worsen hyperkalemia 6, 5

Summary Algorithm

1. Immediate: Evaluate neurological symptoms (calcium, magnesium, phosphate, consider neurology consult) 1
2. Day 1-3: Initiate SZC 10g TID and check potassium/creatinine at day 3 1, 4
3. Day 4-7: Once K+ <5.0, restart losartan 25mg daily and felodipine 5mg daily 2, 1, 4
4. Week 1-2: Transition SZC to 5-10g daily maintenance, recheck labs at day 7 1, 4
5. Week 2-4: Titrate antihypertensives based on BP response, add chlorthalidone if needed 5
6. Ongoing: Weekly potassium checks until stable, then every 2 weeks, then monthly 1, 4
7. Long-term: Nephrology co-management for dialysis planning and CKD complications 2